Registered Name:
Call Name:
Sex (M/F):
Altered (Yes/No):
Birth Date:
Deceased Date:
Cause of Death:
UKC Reg #
UKC Titles:
Other Reg #:
Coat Color:
Red Factor Status:
Coat Length:
Mask (Full, 3/4, 1/2, Open):
Eye Color Right/Left:
Eye Shape (Almond, Oval, Round):
Variety:
Height, Weight, Length:
Factor VII Status:
OFA Cardiac (AKK#, Data, Conclusion):
OFA Patella (AKK#, Data, Conclusion):
OFA Thyroid (AKK#, Data, Conclusion):
CERF (AKK#,Date):
Bite (Scissor, Overshot, Undershot, Straight, Other):
Sire's Name:
Sire's Reg #:
Dam's Name:
Dam's Reg #:
Breeder:
Breeder/Kennel Name:
Owner:
Owner Contact Info (phone, etc, etc):
Other Certifications or Titles (Agility, CGC, Therapy, etc):
Please explain any of the following health issues your dog has experienced
Structure/Joints (pointed out feet, luxating patellas, other):
Cancer/Tumors:
Cardiac (Heart Murmer, PDA, Pulmonary Hypertension, Arrythmia, other):
Seizures:
Reproductive Health (Cryptorchidism, Monorchid, Pyometra, C-sections,Still-borns, conception problems):
Blood Disorders, Factor VII Status, other):
Cleft Palate:
Open Fontenals
Thyroid (Hypothyroidism, Autoimmune Thyroiditis, etc):
Kidney (Stones, Disease, Infection, other):
Hernias (Umbilical, other):
Puppy Strangles:
Liver (Shunts, Disease):
Eyes (Cataracts, Distichiae, Persistent Conjunctivitis, Tear Staining):
Cushings:
Allergies (Drug/Vaccine reactions, Mange, etc):
Any Procedures or health issues not covered:
Any comments on health, temperament, behaviors, titles:
You have my permission to post any info from this survey to the Online database except for:
Please provide your information in case we have questions about the data you provided
Name:
Address:
City:
State: / Province:
Zip / Postal Code:
Phone Number:
Email Address: